Revised Chart II
Core Residency Questions
Texas Higher Education Coordinating Board rule 21.731 requires each student applying to enroll at an institution to respond to a set of core residency questions for the purpose of determining the student’s eligibility for admission purposes as a resident of Texas.
PART A. Student Basic Information. All Students must complete this section.
Name: Date of Birth:
AMCAS ID Number:
PART B. Previous Enrollment. All Students must complete this section.
1. During the 12 months prior to the term for which you are applying, did you attend a college or university in a fall or spring term?
Yes No ___
If you answered “no”, please continue to Part C.
If you answered “yes”, complete questions 2-5:
2. What institution did you last attend? (Give full name, not just initials.)
______Anticipated or actual graduation date: Month Year
3. In which terms were you last enrolled? Please include current term and next/previous term
___ Fall, 20 Spring, 20
4. If you were enrolled in a Texas public institution, did you pay resident (in-state) or nonresident (out-of-state) rates?
___ resident (in-state) ___ nonresident (out-of-state) ___ unknown
5. If you paid in-state tuition at your last institution, was it because you were classified as a resident or because you were a nonresident who received a waiver?
___ resident ___ nonresident with a waiver unknown
IMPORTANT:
If you were enrolled at a Texas public institution during a fall or spring semester within the previous 12 months and were classified as a Texas resident, skip to Part I, sign and date this form and submit it to Baylor College of Medicine.
If you were not enrolled, or if you were enrolled but classified as a nonresident, proceed to Part C.
If you were enrolled at a private and/or an out of state institution during a fall or spring within the previous 12 months, skip to Part C.
PART C. Residency Claim.
Are you a resident of Texas? Yes No ___
If you answered yes, continue to Part D.
If you answered no, complete the following question and continue to Part I.
Of what state or country are you a resident?
If you are uncertain, continue to Part D.
PART D. Acquisition of High School Diploma or GED.
1. Did you graduate or will you graduate from high school or complete a GED in TX prior to the term for which you are applying? Yes No
a. If you graduated or will graduate from high school, what was the name and city of the school?
2. Did you live or will you have lived in TX the 36 months leading up to high school graduation or completion of the GED? Yes No
3. When you begin the 2016 Academic Year, will you have lived in TX for the previous 12 months?
(If you are going to an out of state institution of higher education, please mark NO)
Yes No
4. Are you a U.S. Citizen or Permanent Resident? Yes No
Instructions to Part D.:
♦ If you answered “no” to question 1a or 2 or 3, continue to Part E.
♦ If you answered “yes” to all four questions, skip to Part I.
♦ If you are attending and out of state institution, answer NO to question 3 and continue to Part E.
♦ If you answered “yes” to questions 1, 2 and 3, but “no” to question 4, please request a copy of the Affidavit in Chart III, skip to Part I of this form, and submit both this form and the affidavit to Baylor College of Medicine.
Please do not submit copies of your permanent resident card (green card) or your driver’s license.
PART E. Basis of Claim to Residency.
TO BE COMPLETED BY EVERYONE WHO DID NOT ANSWER “YES” TO QUESTIONS 1a, 2, AND 3 OF PART D.
1. Do you file your own federal income tax as an independent tax payer? Yes___ No ___
2. Are you claimed as a dependent or are you eligible to be claimed as a dependent by a
parent or court-appointed legal guardian? Yes___ No ___
(To be eligible to be claimed as a dependent, your parent or legal guardian must provide at least one half of your support. A stepparent does not qualify as a parent if he/she has not adopted the student.)
3. If you answered “No” to both questions above, who provides the majority of your support?
Self___ parent or guardian___ other: (list) ______
Instructions to Part E.
♦ If you answered “yes” to question 1, continue to Part F.
♦ If you answered “yes” to question 2, skip to Part G.
♦ If you answered “no” to 1 and 2 and “self” to question 3, continue to Part F.
♦ If you answered “no” to 1 and 2 and “parent or guardian” to question 3, skip to Part G.
♦ If you answered “no” to 1 and 2 and “other” to question 3, skip to Part H and provide an explanation, and complete Part I.
PART F. Questions for students who answered “Yes” to Question 1 or “Self” to Question 3 of PART E.
1. Are you a U.S. Citizen? Yes No
2. If you answered no, are you a Permanent Resident of the U.S.? Yes No
3. Are you a foreign national whose application for Permanent Resident Status has been
preliminarily reviewed? Yes No
(You should have received a fee/filing receipt or Notice of Action (I-797) from USCIS showing your I-485 has been reviewed and has not been rejected).
4. Are you a foreign national here with a visa or are you a Refugee, Asylee, Parolee or here under Temporary Protective Status? If so, indicate which. Type
5. Do you currently live in Texas? Yes No
If you are out of state due to a temporary assignment by your employer or other temporary purpose including attending an out of state college or university, please explain in Part H.
6. If you currently live in Texas, how long have you been living here? Years Month
What is your main purpose for being in the state? If for reasons other than those listed, give an explanation in Section H.
Go to College [ ] Establish/maintain a home [ ] Work Assignment [ ]
7. If you are a member of the U.S. military, is Texas your Home of Record? Yes No
What state is listed as your military legal residence for tax purposes on your Leave and Earnings Statement?
8. Do any of the following apply to you? (Check all that apply)
a. Hold the title to real property (home, land) in Texas?
If yes, date acquired: ______
b. Own a business in Texas?
If yes, date acquired: ______
c. Hold a state or local license to conduct a business or practice a profession in TX?
If yes, date acquired: ______
9. While living in Texas [For the past 12 months], have you: (Check all that apply)
a. been gainfully employed [in TX] for at least a consecutive 12-month period? Yes No
b. received services from a social service agency that provides services to homeless persons for at least a consecutive 12-month period? Yes No
10. a. Are you married to a person who could answer “yes” to any part of question 8 or 9? Yes No
b. If yes, indicate which question could be answered yes by your spouse:
c. How long have you been married to the Texas resident? Years Months
Skip Part G and Continue to Part H.
PART G. Questions for students who answered “Parent” or “Legal Guardian” to
Question 3 of PART E.
1. Is the parent or legal guardian upon whom you base your claim of residency a U.S. citizen?
Yes No
2. Is the parent or legal guardian upon whom you base your claim of residency a Permanent Resident?
Yes No
3. Is this parent or legal guardian a foreign national whose application for Permanent Resident Status has been preliminarily reviewed? Yes No
(He or she should have received a fee/filing receipt or Notice of Action (I-797) from the USCIS showing his or her I-485 has been reviewed and has not been rejected)
4. Is this parent or legal guardian a foreign national here with a visa or a Refugee, Asylee, Parolee or here under Temporary Protective Status? If so, indicate which.
Yes No Type
5. Does this parent or legal guardian currently live in Texas? Yes No
If he or she is out of state due to a temporary assignment by his/her employer or other temporary purpose, please explain in Part H.
6. If he or she is currently living in Texas, how long has he or she been living here?
What is your parent’s or legal guardian’s main purpose for being in the state? If for reasons other than those listed, give an explanation in Part H.
Go to College [ ] Establish/maintain a home [ ] Work Assignment [ ]
7. If he or she is a member of the U.S. military, is Texas his or her Home of Record? Yes No
What state is listed as his or her military legal residence for tax purposes on his or her Leave and Earnings Statement?
8. Do any of the following apply to your parent or guardian? (Check all that apply)
Hold the title to real property (home, land) in Texas? Yes No
If yes, date acquired: ______
Own a business in Texas? Yes No
If yes, date acquired: ______
Hold a state or local license to conduct a business or practice a profession in TX? Yes No
If yes, date acquired: ______
9. While living in Texas [For the past 12 months], has your parent or guardian:
(Check all that apply)
Been gainfully employed [in TX] for at least a consecutive 12-month period? Yes No
Received services from a social service agency that provides services to homeless persons for at least a consecutive 12-month period? Yes No
10.a.Is your parent or legal guardian married to a person who could answer “yes” to any part of question 8 or 9? Yes No
b. If yes, indicate which question could be answered yes by your parent or guardian’s spouse:
c. How long has your parent or guardian been married to the Texas resident? Years Months
Part H. General Comments. Is there any additional information that you believe we should know in evaluating your eligibility to be classified as a resident, or that has been requested from previous responses? If so, please provide it below:
PART I. Certification of Residency. All students must complete this section.
I understand that officials of my college/university will use the information submitted on this form to determine my status for residency eligibility. I authorize the college/ university to verify the information I have provided. I agree to notify the proper officials of the institution of any changes in the information provided. I certify that the information on this application is complete and correct and I understand that the submission of false information is grounds for rejection of my application, withdrawal of any offer of acceptance, cancellation of enrollment and/or appropriate disciplinary action.
Signature: ______Date: ______